HIVApplication

First Name*

Last Name*

Telephone*

Email*

JHU School*

Nursing Students! If you are an undergraduate nursing student, you must be enrolled in the School of Nursing's Community Outreach Program in order to participate in the HIV Counseling and Testing Program. Otherwise, please do NOT submit an application.

Degree Program*

Current Year of Degree Program*

Will you be enrolled in school throughout the entire 2011-2012 academic year?*

Yes

Expected Graduation Date*

Do you have access to a car for traveling to a clinic site?*

Yes

NOTE: Access to a car in NOT required, but it may be useful for some of our clinical sites.

Are you willing to utilize public transportation to access a clinical site?*

Yes

Are you able to make a minimum commitment of 2 shifts per month? (shifts are approximately 3-4 hrs in length)*

Yes

Undecided

Are you able to commit to working in the HIV Program throughout the entire 2011-2012 academic year?*

Yes

Undecided

Are you able to commit to attending and participating in quarterly reflection sessions?*

Yes

Undecided

Are you available to work in the HIV Program during the Winter Break? This is not required, but clinics like to know the availability of our students.*

Yes

Undecided

Are you available to work in the HIV Program during Summer 2012? This is not required, but clinics like to know the availability of our students.*

Yes

Undecided

Which of the participating community clinics would you be willing and able to work at for the HIV Counseling and Testing Program? HIGHLIGHT ALL THAT APPLY! Counselors will be assigned to a clinic for the entire academic year. Be sure to review the details on each clinic before selecting.*

Would you be interested in serving as a Student Leader at one of the clinic sites? This entails working directly with the community clinic preceptor, scheduling volunteer shifts with the rest of the student counselors at your site (9 other students), troubleshooting, planning reflection sessions with your clinic and SOURCE, etc.*

Yes

Are you able to pay the $25 required training fee*

Yes

Do you agree to all outlined expectations and requirements of the HIV Counseling and Testing Program?*

Yes

In a separate document (Word or pdf files only please), please respond to the following 5 questions, and upload here. NOTE: You must Name your file "Your Last Name, Your First Name HIV Essay." Also, documents without names on each page of the document will not be considered for the program.
1. Describe previous community or health related experiences (especially with HIV/AIDS) - 1 paragraph.
2. Describe why you want to participate in the HIV Counseling Program. Please also describe your personal characteristics that you believe will contribute to your participation in the program and your career goals. - 1 paragraph
3. HIV Counseling work hours will be divided into several shifts (mornings, afternoons, evenings, and weekends). Though these shifts may be flexible, do you have any potential or known time conflicts?
4. During the upcoming academic term this Fall, please list all available days and times that you would be available to volunteer (include Monday through Sunday, morning through evening hours). We are aware that your available times will change, but the clinics would like to get a sense of the availability of our student applicants.
5. Any other things that you would like the selection committee to know about you or your possible participation in the program (max 1 paragraph)

Upload Responses to Questions 1-5 above (Word or pdf only)